Evidence-Based Falls Prevention Program Application Form

STAGE 1: Research and Effectiveness

TWO-STAGE APPLICATION PROCESS

Stage 1: Research and Effectiveness

Stage 2: Program Implementation – *BY INVITATION ONLY*

APPLICATION SCHEDULE & PROGRAM REVIEW BACKGROUND

Letter of Intent Due (Optional) |November 17, 2017

Stage 1 Application Due |January 19, 2018

Invitations to Submit Stage 2 (Program Implementation) Applications |March 2, 2018

Stage 2 Application Due |April 6, 2018

Notifications to Applicants |Early June 2018

The purpose of the National Council on Aging’s Evidence-Based Falls Prevention Program application is to identify effective community falls prevention programs that meet the criteria established by the Administration for Community Living/Administration on Aging (ACL/AoA) for evidence-based programs funded through the Older Americans Act (OAA) Title III-D (see Appendix A). It is important to note that Title III-D criteria specifically address older adults, but programs submitted through this process may addressfalls, fall risk factors, or fall-related injuries among adults with disabilities..

TheACL-fundedNational Falls Prevention Resource Center (NFPRC),basedattheNationalCouncilonAging(NCOA),isoverseeingthisprocess inpartnershipwiththeEvidence-BasedLeadershipCouncil(EBLC).Together,NCOAandEBLChaveestablishedaReviewCounciltoconducttheassessmentsofprogramssubmittedthroughthisapplicationprocess.TheReviewCouncilconsistsofnationalleaderswithexpertiseinprogramresearch,evaluation,andimplementation.

Theevidence-basedprogramreviewprocessprovidesseveralbenefits:

ProgramswillbereviewedforpotentialinclusionontheACLTitleIII-Dapprovedlistinatimely,unbiasedmanner;
More community-based falls prevention programs that effectively reduce varied fall risk factors and/or population-specific fall risk factors will be available for dissemination;and,
Community,state,andtribalorganizations/agenciescanusetherecommendationsofReviewCounciltoreferenceprogramsthathavebeendeemedtobeappropriateforinclusionforACLTitleIII-Dor other ACL future falls prevention discretionary funding.

Review Criteria

Falls prevention programs submitted for review will be judged based on these criteria:

Demonstratedthrough evaluation to be effective in reducing falls, falls risk factors, and/or fall-related injuries, resulting in improved function, independence and wellbeing among older adults and/or adults with disabilities(see the following section for the definition of Falls Prevention Program Effectiveness);and
Proven effective with older adults and/or adults with disabilities, using Experimental or Quasi-Experimental Design;and
Research results published in a peer-review journal or journals;and
Fully translated in one or more community site(s);and
Includes developed dissemination products that are available to the public.

This application includes questions that address each of these criterion. Failure to answer questions related to any of these criteria will result in an incomplete application.

Falls Prevention Program Effectiveness

Falls prevention program effectiveness is defined as a significant (p<.05) improvement of the intervention group relative to the comparison group in at least one of the following primary outcomes:

Number or rate offalls
Number or rate of fall-related injuries

If falls or fall-related injuries were not the primary outcome of the research, the program must demonstrate significant improvements on a combination of the following fall risk factors:

Biological Risk Factors

Gait
Balance
Strength
Range of motion
Vision
Functional limitations
Postural hypotension
Incontinence

Behavioral Risk Factors

Falls self-efficacy
Physical activity
Fear of falling
Medication modification / management
Depression

Environmental/Safety Risk Factors

Home modifications
Adaptive equipment /mobility aids

This application requires that the instruments/tools/metrics used to measure outcomes be described, and any evidence of their validity, where applicable in the study population.

Please also include any adverse outcomes or events that occurred as part of your program.

NCOA and EBLC would like to draw yourattentiontothetwo-stageprocess,asnotedintheApplicationScheduleatthetopofthisnotice.

1.Stage 1: The first stage application addresses the effectiveness, the evidence base and evaluation details related to the program. Once evaluated by Review Council members with expertise in research and program evaluation, applicants will be notified whether or not they will be invited to complete the second stage of the application. The application that follows is the Stage 1 application.

2.Stage 2 (by invitation only): The second stagewill requireinformationabout the programimplementation, training, dissemination materials,supportsavailable,etc. Ifyourprogramisnotselected tomove onto thesecondstage,youwill beeligibleto receive technical assistanceprovidedby NCOAandEBLC,andwill be able to re-applyduringa subsequentreviewcycle.

Pleasesubmit your Stage 1 application by January 19, 2018.

Your application and all attached materials will not be made public and will kept strictly confidential within NCOA, ACL, and the Review Council.

STAGE 1 APPLICATION, SECTION I: PROGRAM NAME AND CONTACT INFORMATION

Name of Program:

Name of Primary Contact:

Position/Title:

Organization/Institution:

Phone Number:

Email:

Street Address:

City, State, Zip:

** If the Primary Contact is not the prevention program developer, please attach a letter of support from the program developer. **

Co-Authors/Co-Investigators:

Please provide, as applicable, the name, organization, contact information, and role(s) of up to five people, other than yourself, who were instrumental in developing the program, creating implementation/dissemination components, or researching or evaluating the program. (Note: This list should include any co-principal investigators for single-site or multisite trials.)

1. Name:

Position/Title:

Organization/Institution:

Email:

Phone Number:

Role:

2. Name:

Position/Title:

Organization/Institution:

Email:

Phone Number:

Role:

3. Name:

Position/Title:

Organization/Institution:

Email:

Phone Number:

Role:

4. Name:

Position/Title:

Organization/Institution:

Email:

Phone Number:

Role:

5. Name:

Position/Title:

Organization/Institution:

Email:

Phone Number:

Role:

STAGE 1 APPLICATION, SECTION II: PROGRAM OVERVIEW AND RESEARCH

Please answer all questions below. Your submission will be considered incomplete if some questions are not answered. Please be clear, concise and complete in responding. The Evidence-Based Falls Prevention Program Review Council is not able to contact you for additional information. Your submission will be reviewed solely on the information you provide in this application.

Primary outcome/s (Check all that apply):

Number or rate of falls

Number or rate of fall-related injuries

If falls or fall-related injuries were not the primary outcome of the research, the program must demonstrate significant improvements on a combination of the following fall risk factors; please specify how these factors reduced falls, injuries or fall risks in your program:

Biological Risk Factors

Gait

Balance

Strength

Range of motion

Vision

Functional limitations

Postural hypotension

Incontinence

Behavioral Risk Factors

Falls self-efficacy

Physical activity

Fear of falling

Medication modification / management

Depression

Environmental/Safety Risk Factors

Home modifications

Adaptive equipment /mobility aids

Brief Description of Program Goals/Objectives (Maximum of 250 words)

List up to three primary goals of the program.

Target Audience (Maximum of 250 words)

Describe the target audience(s) for whom this program has been evaluated as effective.

Program Setting(s) (Maximum of 250 words)

Describe the community setting in which this program has been evaluated as effective.

Research design

What type of research design did you use for evaluating the program?

Page 1 of 9

Randomized Controlled Trial (RCT)

Quasi-experimental

Single Posttests

Multiple posttests

Page 1 of 9

Other (write-in) ______

Summary of research (Maximum of 800words)

Provide a summary of the research design used for evaluating this program. Please reference the peer-reviewed article(s) that demonstrate(s) the research design. Please also include any adverse outcomes or events that occurred as part of your research.

(Your response should address Review Criterion #2: Proven effective with older adults and/or adults with disabilities, using Experimental or Quasi-Experimental Design.)

Summary of program outcomes (Maximum of 800words)

Describe the outcomesthat are achieved with this program. Please describe the instruments/tools/metrics used to measure outcomes, and any evidence of their validity, where applicable in the study population. Please reference the peer-reviewed article(s) that demonstrate(s) evidence for each outcome listed as well as which table(s) in the research articles provide evidence for each key outcome. Please also include any adverse outcomes or events that occurred as part of your program.

(Your response should address Review Criterion #1: Demonstratedthrough evaluation to be effective in reducing falls, falls risk factors, and/or fall-related injuries, resulting in improved function, independence and wellbeing among older adults and/or adults with disabilities(see the following section for the definition of Falls Prevention Program Effectiveness.)

Published articles (Maximum of 250 words)

Attach up to three articles that have been published about this program in a peer-review journal. Please include studies referenced above (i.e. under “Summary of research”).

(Your response should address Review Criterion #3: Program research results published in a peer-review journal or journals.)

Attach up to three published articles here (PDFs only).

How many subjects were in the original efficacy trial?

Treatment N: ______

Control N: ______

For up to 6 key outcomes, please specify the outcome name and metric (measurement tool), provide the author, year, and related table number from corresponding peer-reviewed publication, timepoints data were collected,the significance (e.g., p=.034), and effect size (where available) for each time point where the outcome was measured (effect size.e.g., baseline/pre, post/6-months, follow-up/12-months).

*Indicates a required field.

Outcome 1: ______

Metric: ______

Author (s)*: ______Year: ______

Table Number(s)*: ______

Time 2: p= _____* effect size = ______